Failure to Prevent Pressure Injury in Resident
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of avoidable pressure injuries for a resident identified as at risk. The facility's policy on 'Pressure Injury Prevention and Management' was not effectively implemented, as evidenced by the lack of a care plan addressing the resident's skin condition and potential risk for pressure injuries. The resident, who was dependent for bed mobility, transfers, toileting, and bathing, was initially assessed as not at risk for pressure injuries upon admission. However, a subsequent assessment indicated a moderate risk, which was not reflected in the care plan. A darkened area on the resident's left heel was identified, but the treatment plan, which included skin preparation, was not documented as ordered or applied. The resident was transferred to the hospital at the family's request and did not return to the facility. Interviews with the facility's new administration and nursing staff revealed that they were in the process of implementing new procedures for skin assessments and care, but these were not in place at the time of the incident. The facility's investigation confirmed the development of a pressure injury during the resident's stay, which was documented and treated according to protocol.
Plan Of Correction
Tag Cited: F686 Treatment/Svcs to Prevent/Heal CFR(s): 483.25(b)(1)(i)(ii) 1. Immediate action(s) taken for the resident(s) found to have been affected include: The facility failed to implement skin integrity interventions for Resident R799. Resident R799 was transferred to hospital and didn't return to the facility. 2. Identification of other residents having the potential to be affected was accomplished by: On the Director of Nursing, Assistant Director of Nursing, and Unit Manager conducted a 100% skin sweep audit for current residents to establish a baseline skin assessment by completed by. On a 100% audit for Braden Assessments was completed for current residents to address moderate to high-risk Braden Scores. This audit was conducted by the Director of Nursing, Assistant Director of Nursing, and Unit Manager completed by. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On the Director of Nursing conducted an audit of all current residents to review and identify those with and/or Braden scores of moderate to high risk by and completed by. Any resident with or Braden Scores of moderate to high had care plans initiated or revised care plan focusing on skin integrity and prevention needs. All new admissions are ordered skin prep to heels for the first 14 days of admission and then reassessed by nurse for further skin integrity needs. A designated treatment nurse was hired on. Starting the Assistance Director of Nursing began re-education for Licensed Nursing staff (RN and LPN) on Care Best Practices including timely documentation. All licensed nursing staff will be educated by, anyone not in compliance with this date will be educated prior to the next working shift. All newly hired licensed nursing staff (RN and LPN) will complete this education during orientation. The facility is not currently utilizing agency staffing. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: Starting the Care Nurse or designee will audit new admissions five times a week for 2 weeks, and 5 new admission records weekly for 4 weeks, to ensure residents with high-risk Braden Scores have appropriate interventions in place for skin integrity. The Care Nurse will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25